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Questions 158

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Question 1 of 5

When performing Leopold maneuvers on a client at 32 weeks gestation, the nurse would expect to find:

Correct Answer: D

Rationale: At 32 weeks gestation, the fetus is active, and Leopold maneuvers typically detect strong, active fetal movement as the fetus grows and develops.

Question 2 of 5

In assessing a person after experiencing spousal abuse, which need has the highest priority?

Correct Answer: C

Rationale: Assessing the level of anxiety, coping responses, and support systems is very important, but not of highest priority at this time. A history of physical abuse is an important part of assessment. The nurses must also always ask if there is abuse of the children. Although all of these answers are very important in assessment, the highest priority is assessment of suicide potential, because this could cause the greatest harm to the client. Feeling there is no other way out, abused spouses may consider suicide. The spouse may be self-medicating herself with alcohol or drugs to escape an awful situation. The abuser may also be abusing drugs or alcohol. If this is so, the nurse should encourage the spouse to seek counseling and not to return to the home.

Question 3 of 5

The nurse caring for a client receiving intravenous magnesium sulfate must closely observe for side effects associated with drug therapy. An expected side effect of magnesium sulfate is:

Correct Answer: B

Rationale: Hypersomnolence (drowsiness) is an expected side effect of magnesium sulfate used for preeclampsia due to its central nervous system depressant effects. Absence of reflexes or decreased respiratory rate would indicate toxicity not an expected effect.

Question 4 of 5

The nurse is preparing to administer a dose of morphine sulfate IV to a client for pain. Which assessment is most important before administration?

Correct Answer: A

Rationale: Morphine, an opioid, can cause respiratory depression. Assessing the respiratory rate is critical before administration to ensure it is above 12 breaths per minute, preventing overdose risk. Other vital signs are monitored but are less critical.

Question 5 of 5

A mother who is breast-feeding her newborn asks the RN, 'How can I express milk from my breasts manually?' The RN tells her that the correct method for manual milk expression includes using the thumb and the index finger to:

Correct Answer: D

Rationale: Compressing and releasing at the outer border of the areola targets the milk sinuses, effectively expressing milk without causing trauma.

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